HomeMy Public PortalAbout5626 MCCULLOCH AVE_Building__ e,"6R#.082/.0 APPLICATION FOR,.. 1
. BUILDING PERMIT
COUNTY OF LOS ANGELES BUILDING
DEPARTMENT OF COUNTY ENGMUR ADDRESs5
BIWING AND SAFETY DMSION LOCALI
JOHN A. LAMBIE, COUNTY ENGINEER NEAREST
WILLIAM A. JENSEN SUPT OF BUILDING CROSS ST.
DISTRICT NO. GROUP TYPEPR ESSED BY
FOR APPLICANT TO FILL IN �!"p CONST:—
BUILDING STATISTICAL CLASSIFICATION SEWER MAP PG
7 �• / BK
ADDRESS[' QQ q C '�J CLASS.NO. A DWELL.UNITS F Q
LOT NOU1-b/Q O r►♦ BLOCK NUMAPMBER w V ST TE 'YES NO
TRACT d USE ZONE SPECIAL
NO.OF BLDGS. / CONDITION
SIZE OF LOT NOW ON LOT !
USE OF
EXISTING BLDG. BUILDINGEXIST.
SETBACK ARD HWY STREET NAME WIDTH
OWNER )i — t 6"` EP.L.
�J q
Inc,
ADDRESS
ARCHITECT OR TEL.
ENGINEER NO. INSPECTION RECORD
ADDRESS
/�! `A,!/"� TEL. f 6 �'=-�!•r:` p��,`?� a
CONTRACTOR C3
NO. ;
ADDRESS ) /.3 7 ;..-��w I.,l Av/� %' .7�•/ V
DESCRIPTION Off' WORK 0
NEW. ADDITER REPAIR DEMOLISH
SO.FT. NO.OF NO.OF
SIZE STORIES FAMILIES / f�
USE OF "'�✓I. ! Zr--f-'T-
STRUCTURE L f / ♦ ., /
lAlew
S I GNATUQ OF � 4
APPLICANT
VALUATION$ I
APPROVALS DATE INSPECTOR'S SIGNATURE
P;C, PMT: q� FOUNDATION:LOCATION �}
FEE I I FEE $ v v FORMS,MATERIALS
FRAME:FIRE STOPS, 1 '
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP- BRACING BOLTS
PLICATION AND STATE THAT THE ABOVE IS CORRECT AND, FURNACE:LOCATION,
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND GAS VENT,DUCTS
STATE LAWS REGULATING BUILDING CONSTRUCTION.
I CERTIFY THAT IN DOING THE WORK AUTHORIZED I LATH,INT.
WILL NOT EMPLOY ANY PERSON IN VIOLATION OF THE
WORKMEN'S COMPENSAT! OFCALIFOR _ LATH,EXT.
SIGNATURE OF HOUSE NUMBER COR-
PERMITTE ' RECT AND POSTED
ADDRESS FINAL
CLYDE N. DIRLAM, PRINCIPAL=ST�c ,.O.
U AL ENGINEER
PLAN.CMC$ VALIDATION cr. M.o. CASH PERMIT .VALIDATION CASH
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�`��"p -4-• APPLICATION; FOR BUILDING PERMIT
t COUNTY OF LOS ANGELES BUILDING AND SAFETY
•� .,� , - BUILD( DR
- '•WORKER S COMPENSATION DECLARATION FOR APPLICANT TO FILL IN
I hereby affirm that I have a certificate of consent to self Insure, BUILDING ADDRESS
or a certificate of Workers'Compensation Insurance,gr a rtifl'
copy thereof(See'3800 Lab.Com) ' CITY ' ' ZIP LOCALITY
POIICy NOj �J Company SIZE LOT I NO.OF BLDGS.NOW ON LOT 06
❑ Certified copy is hereby,furnished. Go y(, 1 NEAREST C
❑ Certified co Is filed with the countybuilding Ins lon
TRACT BLOCK LOT NO.
P 0!369B,5USE ZONE MAP NO.
department.' ^ '
Date--'��PPlicanttOR MAP BOOK PAGE PARCEL i
0 13 O`Z2 1 SPECIAL CONDITIONS
i OWNER TEL.NO.
CERTIFICATE OF EXEMPTION FROM WORKERS' . - [ WITHIN 1000 FT OF SCHOOL?
YES NO
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the permit is-for one hundred DISTRICT JJJ "'GROUP TY ST• FIRE ZONE P ED
dollars($100)or less.) CITY ZIP
I certify that in the performance of.the work for which this permit
Is Issued, I shall not employ any person In any manner so as t0 HITECT OR ENGINEER TEL.NO., �. .5
become subject to the Workers'Compensation Laws. L ..���P ATISTICAL CLASS( (CATION O
Date 'Applicant ADDRESS CLASS NO. DWELL UNITS
NOTICE TO.APPLICANT. If;after making this.Certificateof REQUIRED TOTAL SETBACK FROM . EXIST
Exemption,-you, should become subject to the Workers' CONTRACTOR TEL NO. SETBACK YARD HWY., PROP LINE WIDTH
Compehsation,provisions of the Labor Code,you must forthwith FRONT
comply with such provisions or this permit shall be deemed'revoked. ADDRESS f LIC.NO. PL
LICENSED CONTRACTORS DECLARATION CITY LIC.CLASS PIL C
1 hereby affirm that I am licensed under provisions of Chapterig' SEWER MAP
(commencing with Section 7000)of Division 3 of the Business and NO.OF STORES NO.f FAMILIES'
Professions Code,and my license is in full force and effect. NEW ❑ 9K PG Q.
D ION OF WORK VALUATION ,.t i W.
License Numberl ,j 3 ' Lla Class L ` ADD ` ' a.
ContractoiR40<����Date dl ALTER ❑ ti
Z
❑ I am exempt under Sea REPAIR ❑ $ -
B.&P.C.for this reason DEMOL ❑ LDMAPIC 0
USE'OF EXISTING BLDG.
D URM ❑,
Signaturei.
` AP LICANT(PRINT) TEL NO. LDMA Perm# +elf1
111.as owner of•t e property,•or my em oyees with wages as - " ,p. ,rT°a
their sole compensation,will do the work and the structure is R - r ~
not intended or offered for sale (Settlor 7044, Business and A &9 + FINAL .i/y/, Q 3307 Li
Professions Code.)' wILLTHEAPPUCANTORFUTURE BUILDING OCCUPANTHANDLEAHAZARDOUS MATERIAL / ` T S
OR A MIXTURE CONTAINING A HAZARDOUS MATERIAL EQUAL TO OR GREATER THAN 'J • d[ i!s
❑ I, "'owner-c r Of the property, am exclusively contracting with THE AMOUNTS S FIED ON THE HAZARDOUS MATERIALS INFORMATION GUIDE? FI!2, 3•�•L
• licensed contractors to construct the project.(Section 7044, YES.❑ NQ � TOTAL •��GP.6„90
Business and Professions Code.) IH�(~riti°�7 y
WILL THE INTENDED USE OF THE BUILDING BY THE APPLICANT OR FUTURE BUILDING. S 70
OCCUPANT REQUIREA PERMIT FOR CONSTRUCTION OR MODIFICATION FROMTHESOUTH
CONSTRUCTION LENDING AGENCY COAST AIR QUALITY MANAGEMENT DISTRICT(SCAOMD)SEE PERMITTING CHECKLIST /�[({' I
1 FOR GUIDELINES: _ - �,,` . l�' ° :t'� `-CHANGE,• _ °�'
I hereby affirm that there is a construction lending agency for YES❑ NO
• the performance Of the work for which this permit is issued(SBC. I HAVE READ THE 15OUS MATERIALS INFORMATION GUIDE AND THE SCAQMD•I 1 5'
3097,CIV.C.). ( PERMITTING CHECKLIST,1 UNDERSTAND MY REQUIREMENTS UNDER THE LOS ANGELES •, .. �3 G-13001 _ �/27/90
COUNTY CODE,TITLE2,CHAPTER220 SEC IONS22M100THROUGH 220.140 CONCERNING 5�} /��,;q I-�
Lender's Name I' HAZARDOUS MATERIALS REPORTINO AND FOR OBTAINING A PERMIT FROM THE SCAQMD. 209 4L 1 AM 112-0
Lender's Address L17 rill L
AGOIr
I certify that 1 have read this application and state that the above PC FEE PERMIT FEE.
Information is correct. I agree to comply with all county r�
ordinances and State laws relating to building construction,and vv
hereby authorize representatIm of this Count*w7r
u on. ISSUANCE FEE
the above- red property for In"on U ' ,3
' INVESTIGATION FEE TOTAL FEE Coa. '
E . b
&puWn°1 i ; .
I' SEEREVERSE FOR EXPLANATORY LANGUAGE. ,